NENE'S REST HOME

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on records reviewed, Licensee did not comply with the section cited above. Per incident report, Resident 1 was given Resident 2's medication. This is an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to submit certification that medication training will be conducted for facility staff. Certification to be submitted by due date of 03/25/2025. Training to be submitted by POC due date of 04/03/2025 and include Date, Training Topics, Job Role, Staff Names and Signatures.

Deadline recorded: Mar 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interview and file review, Licensee did not comply with the section cited above and ensure facility is sufficiently staffed. 2 of 3 residents are on hospice with dementia and 3 of 3 residents need assistance with ADLs. Administrator performs caregiving duties full-time. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to submit self-certification email stating that they will enroll in administrator certification course to become the new administrator by POC due date 01/28/2025.

Deadline recorded: Jan 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator... & permit adequate attention to the management & administration of the facility. This requirement was not met as evidenced by: Based on interview and file review, Licensee did not comply with the section above & ensure facility is sufficiently staffed. 2 residents are on hospice with dementia & 3 of 3 residents need assistance with ADLs. Administrator performs caregiving duties full-time. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to provide CCL an update regarding Administrator certification for Staff Member, Dave Miranda. Update to be provided by POC due date of 02/06/2025.

Deadline recorded: Feb 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview with administrator, licensee did not comply with the section cited above. 1 of 4 employees had current CPR and 1st aid, 1 of 4 employees had current CPR and 2 of 4 employees had no CPR or 1st Aid. This poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 01/18/2025 Plan of Correction Llcensee to submit proof of paid enrollment for identified employees needing current 1st Aid and CPR certification. Licensee to submit proof of scheduled enrollment by POC due date of 01/18/2025. LIcensee to sumit proof of certificates once classes are completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, Licensee did not comply with the section cited above. Facility sink temperatures measured at 137.1F, 135.5F, and 126.5F. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 01/28/2025 Plan of Correction Licensee to submit a water temperature log for 10 days for all facility sinks. Temperature to be checked twice a day starting 01/18/2025 and ending 01/28/2025. Log to include time when water was checked. Log to be submitted to CCL for review and approval by POC due date 01/28/2025.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in as 2 out of 2 personnel files were missing annual trainings which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/27/2024 Plan of Correction Licensee is to submit a compliance plan of how all staff will complete annual trainings in a timely manner. Plan of Correction is to be submitted to LPA Yang.